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Proximal Humeral Fracture

- See: Proximal Humeral Physeal Injuries
- Discussion:
      - classification of proximal humeral fractures:
             - anatomic neck fracture:
             - one part fracture
             - two part fractures
                     - two part surgical neck fracture
                     - two part tuberosity fractures:
                            - lesser tuberosity frx;
                            - greater tuberosity frx;
             - three part fractures
             - four part fracture:
             - fracture dislocation:
             - head split fragment:
                      - Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component.t

    - displacing forces:
           - following frx of humerus, frx fragments may be displaced as a result of pull of muscles inserting into two parts;
           - w/ frx of surgical neck, upper frag is usually abducted and externally rotated by the muscles inserting onto greater tubercle,
                      while lower frag is adducted & internally rotated by internal rotators; (see rotator cuff);
           - in frx of shaft, angulation & overriding may result from muscular pull;
           - fractures of the middle & lower third of humeral shaft are frequently associated w/ injuries of the encircling radial nerve;

- Radiographs:
    - an axillary view is mandatory for proximal humeral fractures, as it is the view that shows the most angulation and displacement;
    - ref: Conservative management of proximal humeral fractures: can poor functional outcome be related to standard transscapular radiographic evaluation?


- Non Operative Treatment:
    - references:
           - Functional results following frx of proximal humerus. A controlled clinical study comparing two periods of immobilization.
           - Conservative treatment of fractures and fracture-dislocations of the upper end of the humerus.
           - Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus

- Operative Treatment of Proximal Humerus Fractures: 

            - Lateral Plating Technique
            - Shoulder Replacement

- Complications:
    - Non Union of Humeral Fractures:
    - Avascular Necrosis:
main indicators of AVN:
                  - calcar length ( <8 mm), medial hinge integrity, and anatomic neck fracture
           - Initial post-fracture humeral head ischemia does not predict development of necrosis
           - [Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis?].
           - Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus.
Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis.

    - Vascular Complications:
           - Axillary artery injury secondary to displaced proximal humeral fractures: a report of two cases.
           - Axillary artery injury from humeral neck fracture: a rare but disabling traumatic event 
           - Axillary artery injury after proximal humeral fracture: a review of 2 cases.
           - Vascular Injury Accompanying Displaced Proximal Humeral Fractures: Two Cases and a Review of the Literature
           - Proximal humerus fractures with associated axillary artery injury.
           - Proximal humerus fracture with injury to the axillary artery: a population-based study.   
           - Delayed Radial Nerve Injury from a Brachial Artery Pseudoaneurysm Following a Four-Part Proximal Humerus Fracture: A Case Report and Literature Review.

Job 31:22 (King James Version): Then let mine arm fall from my shoulder blade, and mine arm be broken from the bone.

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